BUILDING 00100/11 Application# (/
Harnett County Central Permitting l "SOC 51 2 (n 2 7
Each section below to be filled out PO Box 65 Lillingion NC 27546
by whomever below Idled
910 893 7525 Fax 910 893 2793 www hamee orgepermits
Must be owner or licensed
contractor Address company Application for Residential Budding and Trades Permit
name 8 phone must match
Owners Name f5isn r2./ Torr// n /12? jo /74 Dale r0/zl/j?
Site Address 7V if/nth/0c.F C/ Phone 9/9-669-7195
Directions to job sitefrom Lillington Y° / 10A/crc/ /ray✓y '•Z /2.yhr w.-7
Lc, e Ate geps /Li/, ai 07 fie / P7C,
Subdivision Vic to/1 ci ////s/ Lot
Description of Proposed Work Ode/ tit, #of Bedrooms 3
Healed SF Unheated SF Finished Bonus Room° iv° Crawl Space / Slab
General Contractor Information
Ind r.., // //19/h Cs, Mr, 919-441 -7995
Building Contractors Company Name I Telephone
/90 ') tIn I/es A/es? RAJ do hoe,. es 44Cf5044, , tu✓q
Address Email Address
SS"Z3 3
License#
e rc r r i
Description of Work a\dd s ce Ono rity Service Size to Amps T-Pole _Yes *---"No
Reba 4i /'^cot SJ/, fe.. 919- &.j- 2993
Electrical Contractor s Company Name / Telephone
ell)! Ov/sr, 40/-
Address Email Address
/o9 e23 -
License#
Mechanical/HVAC Contractor Information
Description of Work
�)) 411 c tt'e'- . q el L/ /
RI/10Sle ddn.e Scat •te 9/9-6V/- 2993
Mechanical Contractors Company Name Telephone
0290)1 brae,- a r
Addres Email Address
3.56 o
License#
plumbma Contractor Information
Description of Work N)J #Bathe
Plumbing Contractors Company Name Telephone
Address Email Address
License#
Insulation Contractor Information
Live VII, it>✓ h
Insulation Contra6tor s Company Name 8 Address Telephone
'NOTE General Contractor must fill out and sign the second page of this application
I hereby certify that I have the authority to make necessary application that the application is correct
and that-the construction will conform to the regulations in the Building Electncal Plumbing and
Mechanical codes and the Harnett County Zoning Ordinance I state the information on the above
contractors is correct as known to me and that py stantna below I have obtained all subcontractors
permission to obtain these Dermas and if yr y changes occur including listed contractors site plan
number of bedrooms building and trade plans Environmental Health permit changes or proposed use
changes I certify it is my responsibility to notify the Harnett County Central Permitting Department of
any and all changes
EXPIRED PERMIT FEES-6 Months to 2 years permit re-issue fee is$150 00 After 2 years re-issue fee
is as per cufee schedule
Signature aF-owner/CContractor/Ofhcer(s)of Corporation Date
Affidavit for Worker's Compensation N C G S 87-14
The undersigned applicant being the
I/ General Contractor Owner Officer/Agent of the Contractor or Owner
Do hereby confirm under penalties of perjury that the person(s) firm(s)or corporation(s)performing the work
set forth in the permit
Has three (3)or more employees and has obtained workers compensation insurance to cover them
Has one(1)or more subcontractors(s)and has obtained workers compensation insurance to cover
them//
✓ Has one(1)or more subcontractors(s)who has their own policy of workers compensation insurance
covering themselves
Has no more than two(2)employees and no subcontractors
While working on the project for which this permit is sought it is understood that the Central Permitting
Department issuing the permit may require certificates of coverage of workers compensation insurance prior
to issuance of the permit and at any timethe p
during ermitted work from any person firm or corporation
carrying out the work 7 J /�
Company or Name ��t% i�,p(� Ai-0
Sign w/Tide , 2/i__—f/ ��t„�/>.,L Date Oh -3//7